1831495803 NPI number — KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Table of content: (NPI 1831495803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831495803 NPI number — KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831495803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BANKS STA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-610-3701
Provider Business Mailing Address Fax Number:
678-610-3703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 BANKS STA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-610-3701
Provider Business Practice Location Address Fax Number:
678-610-3703
Provider Enumeration Date:
02/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SANDERS
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY COMPLIANCE MANAGER
Authorized Official Telephone Number:
770-712-5654

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0003X , with the licence number: PHRE009731 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2127407 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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